0309-266 (RPL)LICENSED CONTRACTOR DECLARATION
(thereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
W, ,+ Professionals Code, and my License is in full force and effect.
o
M, License # Lic. Class Exp. Date
LLJ' C-53 M11 v1r lr�t
oZ r- Date J Signature of Contractor— /•-
U o f OWNER -BUILDER DECLARATION J
HLU I hereby affirm under penalty of perjurythat lam exempt from the Contractor's
License Law for the following reason:
Z( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
CV) () I am exempt under Section , B&P.C. for this reason
mn
O N Date Signature of Owner
rn
it Q WORKER'S COMPENSATION DECLARATION
j Q I hereby affirm under penalty of perjury one of the following declarations:
H O () 1 have and will maintain a certificate of consent to self -insure for workers'
K W 9 compensation, as provided for by Section 3700 of the Labor Code, for the
nJ Q performance of the work for which this permit is issued.
Q U O I have and will maintain workers' compensation insurance, as required by
j U Q Section 3700 of the Labor Code, for the performance of the work for which this
1:
U-) permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier STATE FUND Policy No. 170,4$5 a_ft3
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J (This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: ' Applicant
Warning: Failure to secure Workers' Compensati6n coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a�result of this applicaton agrees to, & shall, indemnity
& hold.harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
f
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City,. and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)';.. f��`- - - �'- Date
BUILDING PER MIT PERMIT m
DATE VALUATION t LOT 0319-2" TRACT '
JOB SITE
APN
ADDRESS :49_120 1p%7I�gACA�d6i 1)1fC��I
OWNER
CONTRACTOR / DESIGNER ! EN &NEER
2M CIRAivJ1 D FADEL
AMM POOLE SPAS
49.120 jUMTkIC)WJ-M DR.
P.O.:k OX 113(31.
LA tjLTLtJTA CSA 92253
PALM. DFMT..,RT SCA 92255
C/60)322-7665 CULA 3352
USE OF PERMIT
POOL. AND/OR SPA
POOL -SPA, ALr't.ii M31JOARRIERS SHALL HE IN PL.ACP PRIOR `3'O
PRE -PLASTER MOPF,t'.`PION
POOL ANDIOR SPA, 5,000, go L,3
ESFIMMEl) COS]' OF C014MMITON
15,000.00
FFIRAW FKE S1'AiIID/ ARY
PLAN CHECK FEE 101.000.409-316 %1as, 30
CONSTRUCTION FEZ 101-100"18-000 '$162.00
MECHANICAL FER -- POOL 101-000-421-000 $24.00
ELEC'Tit1CAlr F9Z -., POOL 101-01YJ 420 -OW $45.00
PLf,1MBINO FRE POOL 10.1.00.0.419.000 $29,00
3T3i-W AL,.COl+TSY RTJC,°r10N AND PLAN CHF)C7C
`F363.30
1AS69 M -PAID FEE 31
a
$0.00
Inn
A , PERMff lIFX6 DUB NOW
SEP 30, 1003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS SPAS
steel — 6 -
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final 1,93
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final -
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
i ' -
1
6' Block Wall PL
%jean
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATALIAL-25 BY S'r
Lawn Area
LA QUINTA GOLF CLUB ESTATES
MOHAMAD FADEL
49120 EISENHOWER DR
LA QUINTA, CA 92253
Existing Home
14'0
Gate
12'0
6' Block Wall PL
14'0
WA
area
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� y
LvJ �-v Jf
1
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATALIAL-25 BY S'r
Lawn Area
LA QUINTA GOLF CLUB ESTATES
MOHAMAD FADEL
49120 EISENHOWER DR
LA QUINTA, CA 92253
Existing Home
14'0
Gate
12'0
6' Block Wall PL
14'0
WA
area
6' Block Wall PL
LA QUINTA GOLF CLUB ESTATES
S
MOHAMAD FADEL
49120 EISENHOWER DR
LA QUINTA, CA 92253
Existing Home